Dr John Short. Obstetrician and Gynaecologist Christchurch Women s Hospital, Oxford Women's Health, Christchurch
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1 Dr John Short Obstetrician and Gynaecologist Christchurch Women s Hospital, Oxford Women's Health, Christchurch 8:30-9:25 WS #142: Peeling Back the Layers - The Pelvic Floor Uncovered 9:35-10:30 WS #152: Peeling Back the Layers - The Pelvic Floor Uncovered (Repeated)
2 Peeling back the layersthe pelvic floor uncovered
3 Relevant anatomy Key concepts of pelvic organ support What constitutes significant prolapse Symptoms Expectations treatment success Conservative treatment options Current surgical trends
4 What s going down there?
5 The pelvis
6 The Pelvic Organs Uterus Bladder Rectum Small bowel
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18 Assessment 0 No Prolapse 1 Halfway to hymen 2 To hymen 3 Halfway past hymen 4 Maximum descent
19 Aetiology Genetics Chronic raised abdominal pressure Pregnancy Childbirth
20
21 Anatomy POP-Q Stage Nulliparous (n=30) 0 13 (43.3%) 1 15 (50.0%) 2a (above the hymen) 2b (at or below the hymen) 2 (6.7%) CS only (n=14) 2 (14.3%) 9 (64.3%) 3 (21.4%) CS & SVD (n=15) 1 (6.7%) 6 (40.0%) 6 (40.0%) 2 (13.3%) SVD (n=84) 31 (36.9%) 34 (40.5%) 19 (22.6%) AVD (n=51) 12 (23.5%) 23 (45.1%) 13 (25.5%) 3 3 (5.9%) 29
22 Anatomy POP-Q Stage Nulliparous (n=30) 0 13 (43.3%) 1 15 (50.0%) 2a (above the hymen) 2b (at or below the hymen) 2 (6.7%) CS only (n=14) 2 (14.3%) 9 (64.3%) 3 (21.4%) CS & SVD (n=15) 1 (6.7%) 6 (40.0%) 6 (40.0%) 2 (13.3%) SVD (n=84) 31 (36.9%) 34 (40.5%) 19 (22.6%) AVD (n=51) 12 (23.5%) 23 (45.1%) 13 (25.5%) 3 3 (5.9%) 29
23 Prolapse beyond the hymen Anatomy vs Symptoms Symptoms determine expectations Expectations determine satisfaction 34 23
24 Satisfaction = Outcome Expectation How is Outcome measured? is it a constant? Therefore satisfaction is directly proportional to expectation Patient s default expectation is glorious rejuvenation
25 Symptoms Bulge Bladder (urge > stress) Bowel sex
26 Goals of treatment Reduce symptoms Maintain function Restore anatomy
27 Conservative treatment options Reassurance Reduce abdo pressure Pelvic floor exercises / pelvic floor safe activities Direct symptom treatment Physical supports
28
29 MEASURING THE WIDTH Insert first two fingers of dominant hand deep to the posterior fornix Approximate size by using the fingers to determine the width Spread fingers wide to measure Remove fingers and compare to pessary sample or fitting kit
30 MEASURING THE LENGTH Reinsert fingers deep into the posterior fornix Make note of where the hand comes into contact with the pubic bone Compare to pessary.
31 INSERTION TECHNIQUE Slide it into the vagina, and curve posteriorly Release and allow to spring open to its normal shape Push deep into the vaginal vault Tuck securely behind pubic bone anteriorly and under the cervix (if present) posteriorly
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35 Surgery
36 the only problem left unsolved by the gynaecologist of the past century is that of permanent cure of Cystocoele
37 if only it were possible to artificially produce tissue of density and toughness of fascia and tendon, the secret of the radical cure of hernia would be discovered
38
39 Mesh is definitely not this year s black!
40 Sand et al yr anatomical success- 40% Re-operation rate- 0%
41 Weber et al 2001 anatomical success- 30% Re-operation rate- 0% (based on grade 0) Based on grade 2a or less 90% Based on symptoms 95%
42 operations Vaginal hysterectomy Anterior and posterior repairs
43 Anterior considerations Apical support Hysterectomy (vag vs lap, +/- suspension) Uterosacral suspension Sacrospinous fixation hysteropexy Vaginal length Specific fascial defects rare
44 Posterior considerations Defect specific repair vs levatorplasty Specific fascial defects very common Perineum Apical support Enterocoele
45 Uterus vs no uterus Level 1 procedures
46 uterus Hysterectomy vs hysteropexy Fertility Patient preference Vaginal vs laparoscopic
47 Prophylactic vault suspension post hysterectomy Grade 3 or greater
48 Sacrospinous hysteropexy Sacro-hysteropexy
49 No uterus Sacro-colpopexy Sacrospinous fixation
50
51 sacrocolpopexy
52 considerations Other prolapse (ant vs post) leading prolapse Previous surgery Body habitus Co-morbidities Patient preference Age
53 Special situations Long cervix Elderly/frail/moribund Recurrent prolapse
54 Special situations Cervical amputation Colpocliesis Mesh
55 colpocliesis
56 Summary Anatomical/functional concepts simple Some degree of prolapse is normal Deterioration is not inevitable Symptoms more important than signs
57 Summary Reassurance may be sufficient for some women Plenty of non surgical options available Physio Pessaries/other devices Surgical trends Less mesh Uterine preservation Colpocliesis (Vaginal obliteration)
58 Any Questions? The End
gynaecology in family medicine
gynaecology in family medicine John Short Obstetrician and Gynaecologist Christchurch john.short@oxfordclinic.co.nz www.christchurch-gynaecologist.co.nz What s going on down there? http://www.youtube.com/watch?v=4-
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